Health inspection·July 28, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Resident 19 was observed lying in bed, on back with head elevated. LN 1 states, Resident 19's buttock redness is new and there is no care plan update or assessment of this wound. During an interview on 7/27/23, at 10:34 a.m. with the Director of Nursing (DON), the DON stated, there is no care plan for preventing or treating buttocks pressure wounds for Resident 19. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 2 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate, and effective system for monitoring parameters of nutritional status when: Residents Affected - Few 1. An order for a therapeutic (to cure or restore to health) liquid nutritional supplement (Mighty Shake) was not documented as being provided and lacked documentation of quantity of consumption of the therapeutic nutrition supplement for effective monitoring pertaining to parameters of nutritional status for one of ? sampled residents (Resident 41). 2. Speech therapist (ST) recommendation for 1:1 supervision during mealtimes was not communicated via an order to ensure the recommendation based on ST assessment would be implemented for Resident 41's health and safety when the texture of a diet order was modified. Failure to consistently ensure nutrition interventions were carried out and monitored had the potential to ineffectively evaluate nutrition interventions and delay an alternative nutrition approach, if necessary, to help prevent or minimize a potential negative outcome. Findings: 1. During an observation on 7/25/23, at 12:27 p.m., in the main dining room, Resident 41 was served her lunch and a Mighty Shake (liquid nutrition supplement to increase calories and protein intake) was not provided. During a concurrent observation and interview on 07/26/23, at 08:59 a.m., with Resident 41, in Resident 41's room, Resident 41 stated, she used to get supplement shakes and she liked them, but she doesn't get them often. Resident 41 stated, she was aware she had lost weight but is eating well and trying to put on weight. During an observation on 7/26/23, at 12:45 p.m., in the main dining room, Resident 41 was served her lunch and a Mighty Shake was not provided. During a review of Resident 41's electronic medical record (EMR), the EMR, under Census tab, indicated Resident 41 was admitted to the facility on [DATE], and left the faciity on 5/20/2023. During a review of Weights and Vitals Summary, Resident 41 weighed 119 pounds (lbs) on 5/09/2023, and 112 lbs on 05/15/2023, a 5.9% (percent) significant weight loss. During a review of Resident 41's EMR, under Census tab, indicated Resident 41 returned to the facility on 6/20/2023. During a review of Resident 41's Minimum Data Set (MDS) (MDS - a standardized assessment and care planning tool) admission Assessment, dated 6/27/2023, the MDS indicated, K0300. Weight Loss; Loss of 5% or more in the last month or loss of 10% or more in last 6 months was marked as Yes, not on physician-prescribed weight-loss regimen. During a review of Resident 41's Weights and Vitals Summary, Resident 41 weighed 108 lbs on 6/26/2023, and weighed 106 lbs on 7/10/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 3 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 41's Nutritional Risk Assessment-Alternate (NRA), dated 6/27/2023, the NRA included, UBW [usual body weight] per CDL [California Driver License): 110 # (pounds) .Goal Weight: 103 113 # ., PO (by mouth intake) averaging ~40-45% of meals, meeting ~69-85% of estimated energy needs and 67-74% of estimated protein needs .Oral intake: Fluids: Consumes < 1,000 cc [cubic centimeter; a measurement of volume]/[per]day, Recommended fluid intake: 1425 - 1600/d [day]. She is drinking 360-720 cc/d per ADLs [activities for daily living documentation]. Fluid intake needs to be encouraged . During a review of Resident 41's Nutrition/Dietary Note, dated 7/12/2023, the Registered Dietitian (RD) documented, [name of resident] weight has dropped since her first admission. Initial admit weight: 5/9/23: 119#. Weight this admission: 108#, with a subsequent drop to 106.0# .MD notified via fax with the recommendation to add a Mighty Shake at breakfast and one in the afternoon. P[plan]) Follow progress, weekly weights. During a review of Resident 41's breakfast meal tray ticket (that provides direction to kitchen staff on what food, portion sizes and supplements to place on the meal tray), dated 7/25/2023, there was no direction to provide a Mighty Shake on the breakfast meal tray for Resident 41. During a review of the facility's Meal Times, the posted breakfast meal time for the dining room was 7:30 a.m. During a concurrent interview and record review on 07/27/23 at 01:47 p.m., with Licensed Vocational Nurse (LN) 2, Resident 41's Order Summary Report (OSR), dated 5/09/2023 was reviewed. LN 2 stated, Ensure (a liquid nutrition supplement to add calories and protein intake) BID [two times a day] between meals was ordered on 5/9/2023 and discontinued on 5/20/2023 because she was not drinking the Ensure. LN 2 reviewed the OSR, dated 7/12/2023 and stated Mighty Shake two times a day for Supplement was ordered to provide to Resident 41 at 0800 (8 a.m.) and 1400 (2 p.m.). During an observation on 7/27/23, at 2:45 p.m., in Resident 41's room, Resident 41 was not observed in her room. There was no Mighty Shake observed on Resident 41's bedside table. During a concurrent observation and interview on 07/27/23, at 02:47 p.m., with Resident 41, in the living room, Resident 41 was observed watching television with her husband. Resident 41 was asked if she received a Mighty Shake at 2 p.m., and she requested more of a description. Resident 41 was informed the Mighty Shake was a small carton and was like a protein shake. Resident 41 stated, she hadn't seen one but they did mention she needed it. Resident 41's husband asked Resident 41 if she wanted it, and Resident 41 stated, Sure. During a review of Resident 41's Minimum Data Set admission Assessment, dated 6/27/2023, the MDS indicated, Resident 41 had a BIMS (Brief Interview for Mental Status) score of 13 which indicated cognitive response (thought process) was intact. During a concurrent interview and record review on 7/27/23, at 3:30 p.m., with LN 2, Resident 41's Medication Administration Record (MAR), dated July 2023 was reviewed. LN 2 stated, the MAR did not list the order for Mighty Shake at 0800 and 1400 as expected because the order got incorrectly entered in the EMR under dietary supplement and not under medication for it to print out on the MAR, as expected by the facility. LN 2 verified there was no documentation by the facility that the order for Mighty Shake two times a day at 8 a.m., and 2 p.m. was implemented, as ordered fifteen days previously. LN 2 stated, she was going to enter the order correctly now so that it would show up on the MAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 4 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm and be able to be tracked and documented as given. LN 2 stated, the facility does not document quantity consumed of the Mighty Shake for monitoring. LN 2 stated, the facility expectation was for the order to have been on the MAR and then nurse's document the order was implemented as signified by a check mark. LN 2 repeated the facility does not document and monitor quantity consumed of Mighty Shake nutrition intervention. Residents Affected - Few During a review of Resident 41's Order Summary Report (OSR), dated 5/9/2023, the OSR indicated, Ensure BID between meals two times a day. During a review of Resident 41's Medication Administration Record (MAR), dated May 2023, the MAR included, Ensure BID between meals two times a day; at 1000 (10 a.m.) and 1430 (2:30 p.m.) D/C [discharged ] date 05/20/2023 with a check mark and nursing initials on each day next to 10 a.m., and 2:30 p.m. until discontinued on 5/20/23. The May 2023 MAR showed the Ensure order, dated 5/9/23 - 5/20/23 was implemented by nursing, as ordered, but lacked documentation on quantity of consumption of the nutrition intervention that was ordered as an addition to the standard breakfast, lunch and dinner mealtimes. During a concurrent interview and record review on 7/27/23, at 3:50 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 showed Resident 41's meal intake percentages located on a clipboard, and CNA 3 stated, the CNA's document food intake on the form located on the clipboard which gets transferred to the EMR. CNA 3 stated, if a resident gets a supplemental shake, that is noted as part of the meal as a whole and recorded into the overall meal percentage. CNA 3 verified a Mighty Shake order does not get documented, and monitored, separately above and beyond the usual breakfast, lunch and dinner meal. During a review of Resident 41's Nutrition Report where the average percent of meal intake for the week (including any intake of a Mighty Shake per CNA 3) gets documented in the EMR was reviewed, dated 7/13/2023 - 7/27/2023. There was no specific documentation that the physician order for Mighty Shake at 8 a.m. and a Mighty Shake at 2 p.m. was implemented/provided to Resident 41, as ordered. During a concurrent interview and record review on 07/27/23 at 4:06 p.m., with Director of Nursing (DON), Resident 41's July 2023 MAR was reviewed in the EMR. DON verified the facility did not have documentation to show the order for Mighty Shake BID, at 0800 and 1400, ordered on 7/12/2023, was implemented. DON verified the facility expectation was for the nutrition supplement order to have been entered in the EMR so that it would automatically print on the MAR for the nursing staff to ensure the order was given. During the same interview with DON, DON stated it was the facility expectation for CNAs to document the quantity of cc's consumed of the Mighty Shake into the overall cc of fluid intake. DON verified the overall cc of fluid intake could be from a variety of fluid sources, and not just from the Mighty Shake. DON verified the facility had not had a system, nor trained nursing staff, to document the specific quantity consumed of the nutrition intervention (Mighty Shake) separately above and beyond the usual fluids and/or meals provided to a resident. DON acknowledged lack of monitoring consumption of a planned nutrition intervention could impede the accuracy of the Registered Dietitian's nutrition assessment and could impede the ability to evaluate the effectiveness of the intervention, or the need to revise a nutritional approach in a timely manner, without relying on a potential negative outcome such as further unplanned weight loss to determine if the intervention was adequate or not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 5 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 41's Interim admission Care Plan, dated 6/20/23, the Problem/Need column under Nutrition/hydration/eating indicated, Hx [history] of dehydration, hx of weight loss, hx of malnutrition, hx special diet, hx swallowing problems . Approaches included to monitor intake and output, monitor percent intake, RD assessment . During a review of the facility's policy and procedure (P & P) titled, Care Planning, dated February 11, 2020, the P & P indicated, Purpose: To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions. Approaches are the individualized interventions that staff will do to help resident reach their goal . During a review of the facility's P & P titled, Subject/Title: Maintaining Acceptable Parameters of Nutritional Status, dated March 8, 2017, the P&P indicated, The purpose is to ensure the resident maintains, to the extent possible, acceptable parameters of nutritional status and that the facility: .Chart review: Review meal intake; .Review acceptance of nourishment .team members will .assure implementation of interventions .Definitions: 'Parameters of nutritional status' refers to factors (e.g., weight, food/fluid intake .that reflect the resident's nutritional status. During a review of the facility's P & P titled, Physician Orders/Recap System, dated July 1, 2014, the P & P indicated, Purpose: To ensure that physician orders are complete, clear and accurately reflect the physician's plan .and carried through properly . 2. During an observation on 7/25/23, at 12:27 p.m., in the main dining room, Resident 41 was sitting in her wheelchair at a dining table with three other residents around the dining table. During a concurrent observation and interview on 07/26/23, at 11:42 a.m., with Resident 41, in Resident 41's room, Resident 41 stated, the food tastes good but she doesn't like the texture when it is all cut up. Resident 41 stated, prior to admission she cut her own food. During an observation on 7/26/23, at 12:45 p.m., in the main dining room, Resident 41 was sitting in her wheelchair at a dining table with other residents around the dining table. During a review of Resident 41's electronic medical record (EMR), under Census tab, indicated Resident 41 was re-admitted to the facility on [DATE]. During a review of Resident 41's Order Summary Report (OSR), dated 6/20/2023, the OSR indicated, Regular diet Minced and Moist texture . (A minced and moist diet consist of food that is soft, moist, 4 mm (A millimeter is a unit measuring length ) by 4 mm in size and needs very little chewing per IDDSI. The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures.) During a review of Resident 41's Speech therapy evaluation of swallow (STE), dated 6/21/2023, the STE indicated, Patient presents with oral and suspected pharyngeal dysphagia [inability to push food from the mouth into the esophagus] based on clinical swallow evaluation completed this date .Patient also with prolonged mastication [inefficient chewing] and mild oral residue [incomplete clearance of food from the mouth] which worsened with regular diet texture. No overt s/s [signs and symptoms] aspiration [food going into airway] on puree solids or soft solids. Given overt s/s aspiration observed at the bedside and progressive nature of underlying PD [Parkinson's Disease; a progressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 6 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disease of the nervous system], recommend further MBS [modified barium swallow; is a fluoroscopic procedure designed to determine whether food or liquid is entering a person's lungs]evaluation in order to inform current swallow function, least restrictive/safest diet recommendations, and baseline in the setting of disease progression. In the interim, recommend soft and bite sized solids (IDDSI 6) [Soft and bite sized diet, SB 6 per IDDSI may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft & Bite-Sized foods need a moderate amount of chewing. The pieces are ' bite-sized ' , 1.5 cm [centimeter; a unit of measurement] by 1.5 cm, to reduce choking risk] with thin liquids by single sip ONLY, 1:1 supervision during meals, oral care following all meals. Recommend close monitoring of patient respiratory status and tolerance of current recommendations . During a review of Resident 41's Diet Order & Communication (DOC) form, dated 6/21/23, completed by the Speech Therapist (ST), the DOC indicated, Diet Order: Regular, Texture: IDDSI Level 6. During a review of Resident 41's meal tray card (used by dietary staff for directions on what type and quantity of food to serve the resident), dated 7/25/2023, listed texture IDDSI Level 6: Soft and Bite-Sized. During a concurrent interview and record review on 07/27/23 at 03:04 PM, with the Director of Rehabilitation (DOR) and the Occupational Therapist (OT), Resident 41's STE, dated 6/21/2023 was reviewed. The DOR and the OT verified that Resident 41 eating in the main dining room was not 1:1 supervision that was assessed and recommended by the ST. Both the DOR and the OT reviewed the ST's order that was placed in Resident 41's paper medical chart and verified the ST mistakenly did not include the 1:1 supervision in the order, when the diet order was changed from minced and moist texture to soft and bite-sized texture. ST was not at the facility to interview, however, the DOR communicated with ST via text and DOR verified ST forgot to put 1:1 supervision in the order located in the paper medical record. The DOR stated, the ST was new to the facility and had not had access to the EMR where the order should have been entered. During a concurrent interview and record review on 07/27/23 at 4:06 p.m., with Director of Nursing (DON), Resident 41's STE, dated 6/21/2023, was reviewed. The DON verified the ST order located in the paper medical record had omitted the ST recommendation for 1:1 supervision and therefore did not get implemented, and should have been. During a review of the facility's policy and procedures (P & P) titled, Physician Orders/Recap System, dated July 2, 2014, the P & P indicated, Purpose: To ensure that physician orders are complete, clear and accurately reflect the physician's plan .and carried through properly ., Record Keeping: All documentation pertaining to Physician orders shall be maintained in the resident's medical record. Current month's administration records will be maintained in the Point Click Care eMAR System . During a review of the facility's P & P titled, Speech- Language Pathologist, dated 7/29/17, the P & P indicated, Duties and Responsibilities: .Develop and implement treatment plans ., complete all documentation in resident's chart including care plans, telephone orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 7 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure a nutrition services employee had the appropriate competency and skill set to carry out the function of accurately completing the Dishmachine Temperature Log. The facility failure to have accurate documentation of dish machine temperatures and lack of monitoring of the dishmachine temperature log impeded the facility's ability to identify temperature problems that could have occurred for prompt resolution to ensure the health and safety of residents. Findings: During a concurrent observation and interview on 07/25/23, at 10:36 a.m., with Nutrition Services employee (NS) 4, in the main kitchen, NS 4 was observed running resident dishes through the high temperature dish machine. NS 4 stated, he was responsible for completing the Dishmachine Temperature Log (DTL). In the presence of the Director of Nutrition Services (DNS), who translated in Spanish to NS 4, NS 4 was asked to show or explain how he documented the temperature for the Wash Temp [temperature] column located on the DTL. NS 4 showed the wash water temperature that displayed on the digital screen affixed to the dish machine that indicated, wash 157.3 degrees F [Fahrenheit] . NS 4 then pointed to the Wash Temp column located on the DTL. NS 4 verified the DTL indicated 181 under Wash Temp column, and 186 under Rinse Temp on the DTL. NS 4 repeatedly stated the 181 temperature on the wash temp column on the log was the wash temperature. NS 4 was asked multiple times, in Spanish by DNS, to point to the thermometer used to record a temperature of 181 degrees F that was located on the DTL. NS 4 continually pointed to the external thermometer located on the dish machine labeled as wash water temperature, and to the digital display that indicated the wash water temperature, however the wash water temperature was not observed to reach 181 degrees F. DNS pointed to another temperature gauge that was located toward the side, and further back from the dish machine that was labeled as the final rinse temperature gauge and asked NS 4 if that was the temperature gauge that was used to record the temperature of 181 degrees F that was located on the Wash Temp column on the DTL, and NS 4 stated, yes. DNS verified NS 4 was not completing the DTL log correctly. During a review of the manufacturer's plate affixed to the high temperature dishmachine indicated, Hot Water Sanitizing; Final Sanitizing Rinse Minimum Temperature: 180 degrees F, Pumped Rinse Tank Minimum Temperature: 160 degrees F, Wash Tank Minimum Temperature: 150 degrees F . During a concurrent interview and record review on 07/25/23 at 10:41 a.m., the DTL log, dated July 2023, from 7/1/23 through lunch time on 7/25/23 was reviewed with DNS. DNS verified the Wash Temp column had documented temperature of at least 180 degrees F for twenty-five days of July 2023 even though the wash water temperature does not reach 180 degrees F. DNS verified multiple nutrition services staff that had their initials on the DTL for documenting wash water temperatures had not documented the wash water temperature accurately. DNS verified that the final rinse temperature gauge located more on the side, and toward the back, of the dish machine was the final rinse temperature that needed to reach at least 180 degrees F for the dishes/utensils to be sanitized. DNS acknowledged that the monitoring of the dish machine temperatures located on the log was inaccurate. During a review of the facility's policy and procedure (P&P) titled, Recording of Dishmachine Temperatures, undated, the P&P indicated, Read temperature gauges on top of the machine while racks are in machine. Record temperatures daily on Dishmachine Temperature Log .Wash Temperature High (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 8 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Temperature Dishmachines : 140 - 160 degrees F, Rinse temperature greater than or equal to 180 degrees F. Any inaccurate temperatures must be brought to the attention of the Dining Services Director immediately ., Dishmachine Temperature Log (Form 408): a. To ensure that the wash and rinse temperatures are properly monitored and controlled, a log must be completed by those who are directly involved in the dishwashing process. Entries must be made for each meal. b. Post the log in the immediate vicinity of the dishwashing area. c. Wash and rinse temperatures must be entered in the log by the dishmachine operator three times daily. d. Actual temperatures must be entered in the log by the dishmachine operator three times daily. e. Report temperatures that are less than the required levels (see above) to the Dining Services Director and immediately convert to paper service until the temperature is corrected. Event ID: Facility ID: 056353 If continuation sheet Page 9 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the menu as planned when: 1. The SB 6 (Soft, Bite Sized Food) diet was not followed related to the size of meat in accordance with the facility's planned menu, and Diet Manual for SB 6 diet for two of 14 sampled residents (Resident 35 and Resident 3). 2. A regular portion diet was not followed per the planned menu, and diet order, for one of 14 sampled residents (Resident 8) when small portions were served by a cook in the main kitchen. This failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. In addition, not following the correct size of meat for a SB 6 diet had the potential to place resident's at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 07/25/23, at 12:19 p.m., in the kitchenette next to the main dining room, licensed nurse (LN) 1 was observed lifting the lid that covered Resident 3's lunch plate and compared it to Resident 3's diet order listed on Resident 3's meal tray card (a meal tray card indicates resident specific diet orders/textures, and instructions on food items that should be on the meal tray, food allergy, and supplements, if any, for example). LN 1 stated, Resident 3's diet order texture was Soft and Bite-Sized. LN 1 was asked if she was trained on what size meat constituted Bite-Sized, and she said she did not know. LN 1 was asked if Bite-Sized meant half inch sized pieces of meat, and LN 1 stated, she did not know but there were pieces of meat (pork loin) larger than half-inch and proceeded to hand Resident 3's lunch tray to a certified nursing assistant (CNA) to provide to Resident 3. During a concurrent observation and interview on 7/25/23, at 12:21 p.m., in the kitchenette next to the main dining room, LN 1 was observed checking Resident 35's lunch meal plate and compared it to the Soft and Bite-Sized diet order texture listed on Resident 35's meal tray card, and LN 1 verified the pieces of meat (pork loin) were larger than half inch and proceeded to hand Resident 35's lunch meal tray to a CNA to serve to Resident 35. During a concurrent observation and interview on 07/25/23, at 03:41 p.m., the Director of Nutrition Services (DNS) observed pictures that were taken of Resident 3's, and Resident 35's lunch meal plate and meal tray card during the lunch meal observation earlier on 7/25/23. DNS stated, the pieces of pork loin served on the IDDSI 6 Soft and Bite-Sized diet (SB6) were too large. DNS verified the meal tray card for the Soft and Bite-Sized diet indicated to serve 3 oz. (ounces) SB [soft & bite-sized) 6 Pork Loin. The meal tray card used by LN 1 to compare the contents of the meal tray had not provided detailed guidance on what size meat to look for in order to ensure compliance with the diet order texture. During a concurrent interview and record review on 7/25/23, at 3:45 p.m., with DNS, DNS reviewed the therapeutic menu spreadsheet for SB6 that nutrition services staff had available during lunch trayline (assembly of resident meal trays in accordance with the planned menu and resident specific meal tray cards), and DNS stated, the therapeutic menu spreadsheet had not provided direction to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 10 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cook on the size of meat to serve for SB6 diet orders. DNS stated, the cook was instructed on bite-sized pieces of meat via an in-service, on 3/15/2023, and was shown pictures of bite-sized pieces for an illustration. During a concurrent observation and interview on 07/26/23, at 10:04 a.m., the Registered Dietitian (RD) observed pictures that were taken of Resident 3's, and Resident 35's lunch meal plate, including the pork loin, and meal tray card during the lunch meal observation earlier on 7/25/23. RD stated, the pieces of pork loin were too large for a SB6 diet. During a review of the facility's approved diet manual, dated 2/22/23, for the IDDSI Level 6 Soft & Bite-Sized Food for Adults (SB6), the SB6 diet indicated, This diet is used for individuals with chewing or swallowing issues. Biting is not required but chewing is required, and sizes of food pieces minimize choking risk ., Meat cooked tender and chopped to pieces are no bigger than 1.5 cm [centimeter; a unit of measurement] x 1.5 cm lump size. During a review of Resident 3's Order Listing Report (OLR), dated 7/25/2023, the OLR indicated, Regular diet Soft and Bite-Sized texture ., ordered on 4/20/2023. During a review of Resident 35's Speech Therapy Treatment Encounter (STTE), dated 5/27/2022, the STTE indicated, Pt [patient] demonstrated coughing 1 x with soft and bite sized .D/C [discontinue] pt from ST [speech therapy] services d/t [due to] pt on safest and least restrictive diet ., continue utilizing safe swallow strategies and continue current diet of soft and bite sized with ground meat and thin liquids with close supervision . During a review of Resident 35's OLR, dated 7/25/2023, the OLR indicated, Regular diet Soft and Bite-Sized texture, Regular consistency, ground meat, may have smooth soft bread, no nuts, sees, no hard rolls. May have regular texture soup, ordered on 3/26/2022. During a review of the facility's policy and procedure (P&P) titled, Diet Manual, Updated 08/2014, the P&P indicated, Policy: A current therapeutic diet manual approved by the Dietitian and Medical Director is readily available to attending Physicians, Nursing, and Dietary Department personnel in order to ensure that all therapeutic diets are prepared as ordered by the attending Physician . During a review of the facility's P & P titled, Physician Orders/Recap System, dated July 2, 2014, the P & P indicated, Purpose: To ensure that physician orders are complete, clear and accurately reflect the physician's plan .and carried through properly . During a review of the facility's P & P titled, Accuracy of Tray Line, undated, the P & P indicated, Policy: Tray line positions and set up procedures are planned for an efficient and orderly delivery system. All trays are checked by dietary personnel for accuracy. Trays are also checked by the employees serving the trays before giving the tray to the resident. Procedure: 1. The menu extension sheet displays food items and amounts for each kind of diet ., The tray is checked against the spread sheet to ensure that foods are served as listed on the menu. Staff will refer to the tray card for dislikes and substitute appropriately for those items .Each tray will be checked for correct name, room number and diet order, accuracy of following diet extension, proper portion sizes, special requests (food preferences) ., Problems with tray accuracy are resolved immediately. Ongoing problems are brought to the attention of the dietary manager. 2. During a concurrent observation and interview on 07/26/23, at 12:05 p.m., in the presence of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 11 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director of Nutrition Services (DNS), a cook (Nutrition Services 1) NS 1, in the main kitchen, NS 1 was observed using a blue handled scoop to serve puree noodles and puree green beans onto Resident 8's plate. NS 1 pointed to the blue handled scoop located in the pan of puree noodles, and another blue handled scoop in the pan of puree green beans, and NS 1 stated, They are both a #16 scoop size. There were no other scoops observed located in the pan of puree noodles and the pan of puree green beans. DNS verified the blue handle scoop was a #16 scoop size, and should not have been used to serve Resident 8 puree noodles and puree green beans as he was on a regular portion size diet, verified by Nutrition Services employee (NS 2), who called out the diet order to NS 1. DNS was asked if it was the correct size to use, and DNS told NS 1 to use a gray handled scoop (#8 scoop) for the puree noodles and puree green beans for a regular portion diet for Resident 8. NS 1 proceeded to obtain two gray handled scoops and placed them next to the blue handled scoop that was to be used for small portion diet orders, only. During a review of Resident 8's meal tray card (MTC), the MTC indicated, Diet: Regular, Texture: IDDSI Level 4: Pureed, .1/2 cup PU4 (puree) Noodles & sauce, 1/2 cup PU4 green beans . During a review of the facility's policy and procedure (P&P) titled, Standard Serving Portions, undated, the P&P indicated, Policy: .#16 scoop = 1/4 cup, #8 scoop = 1/2 cup . During a review of Resident 8's Order Listing Report (OLR), dated 7/27/2023, the OLR indicated, Regular diet Pureed texture . During a review of the facility's P & P titled, Standard Portions, undated, the P & P indicated, Policy: Uniform food portions shall be established for each diet and served to all residents. Procedure: 1. Provide proper equipment for portioning out the correct quantity of food for the residents, 2. Instruct all Dietary employees in the procedures of standardized portions. 3. Recipes and menus should have appropriate portions noted. 4. The Dining Services Director should monitor the cooks and their use of portion control utensils on the steamtable/serving area. During a review of the facility's P & P titled, Accuracy of Tray Line, undated, the P & P indicated, Policy: Tray line positions and set up procedures are planned for an efficient and orderly delivery system. All trays are checked by dietary personnel for accuracy ., Tray line positions for breakfast, lunch and dinner are determined and planned: According to the menu . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 12 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure safe food handling and sanitation when: Residents Affected - Some 1.Expired pizza sauce per the facility's refrigerated shelf- life guidance was available for use in the walk-in refrigerator. 2. Opened bag of cheese was not dated when opened to have a system to follow the facility's Refrigerated Storage Chart, shelf-life guidance. 3. The dry food storage room stored an undated opened bag of pasta, multiple large, unopened canned foods not dated with a received date, ingredient bins containing flour, and thicken-up were not dated, and a dented can of tuna was available for use. 4. The wall located by the clean side of the high temperature dish machine had extensive black colored substance on the surface of the wall. And the covers to the light fixture in the dish machine room were cracked and broken which posed a risk for foreign object cross-contamination. 5. The preparation of cantaloupe was not done in accordance with food safety standards of practice. 6. The facility lacked temperature monitoring of the refrigerator located in the rehabilitation dining room that stored nourishments for residents. As a result of the above findings the residents were placed at an increased risk for foodborne illness and/or diminished quality of food. Findings: 1. During a concurrent observation and interview on 7/25/23, at 9:53 a.m., with Director of Nutrition Services (DNS), in the walk-in refrigerator in the main kitchen, DNS observed a pan covered with tin foil, dated 7/15/23. DNS stated, it's pizza sauce. DNS was asked how nutrition services staff would know how long the pizza sauce could be stored, and DNS stated, We usually keep things for about a week. DNS stated, the facility had shelf life guidelines posted on the refrigerator that staff were to follow. DNS reviewed the Refrigerated Storage: Quick Reference Guide (DOC 409), that was posted on the refrigerator, and pointed to tomato sauce and said the pizza sauce could be stored in the refrigerator, after opening, for five days. DNS stated the pizza sauce should have been thrown away as it was expired. During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 2011, the P&P indicated, .Food items should be stored .in accordance with good sanitary practice. Any expired or outdated food products should be discarded .Refrigerated Storage Quick Reference Guide (DOC 409) may be used for a more efficient method of noting use by dates on products . 2. During a concurrent observation and interview on 7/25/23, at 9:58 a.m., inside the walk-in refrigerator, was an opened bag of cheese without and open date, and DNS stated, the cheese should have had a date when opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 13 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 2011, the P&P indicated, .Food items should be inspected for safety and quality and be dated upon receipt with the exception of herbs and spices, when open, and when prepared. Use Use-By dates on all food stored in refrigerators ., Refrigerated Storage Quick Reference Guide (DOC 409) may be used for a more efficient method of noting use by dates on products . During a review of the Refrigerated Storage Quick Reference Guide (DOC 409), the guide indicated cheese should be used within two months, once opened. 3. During a concurrent observation and interview on 7/25/23, at 10:06 a.m., in the dry food storage room, was an opened bag of dry, uncooked pasta, and the DNS stated, there was not an opened date and should have been. Additionally, there were multiple large, unopened canned food without a receive date. DNS stated, some of the cans come with a manufacturer's use by or best by date, but not all cans are dated. DNS stated, he had not required staff to date the cans that had not had a manufacturer's date, with a receive date. DNS stated the facility had dry food storage shelf life guidelines, and acknowledged that without a receive date the facility did not have a method to follow the facility's dry food storage guidelines. During a concurrent observation and interview on 7/25/23, at 10:09 a.m., in the dry food storage room, in the main kitchen, there was a dry ingredient storage bin that was labeled as flour, undated. DNS was asked if he expected staff to date the bin when the flour was placed in the ingredient bin, and DNS stated, Guess they should. There was another 20 quart- sized dry ingredient storage bin labeled as Thicken-up that was half full, undated. DNS was asked if he would expect the Thicken-up to be dated, either with a date the thicken-up was placed in the bin, or a use- by date, and DNS stated, I guess. During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 2011, the P&P indicated, .Food items should be inspected for safety and quality and be dated upon receipt with the exception of herbs and spices, when open, and when prepared ., use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Charts (POLs 154a, 154b, 154c) found in this section .Remember to cover, label and date! .Dry Storage .Any opened products should be placed in seamless plastic or glass containers with tight-fitting lids and labeled and dated ., Remove food stored in bins from their original packaging. Label and date all storage containers or bins ., Refer to the Dry, Refrigerated And Freezer Storage Chart .These timeframes are not only used to control sanitation but the quality of the food also. Following is a recommended outline of proper storage times for opened and unopened dry, refrigerated and frozen items. Where different, follow manufacturer's directions and expiration dates . During a concurrent observation and interview on 7/25/23, at 10:10 a.m., there was a dented 4 lb (pound) ounce, unopened, can of Chicken Chunk Albacore on a shelf, available for use. The dented can was observed to have a deep dent and dent along the rim of the can. DNS stated the dented can of tuna was acceptable to use for residents, and DNS left the dented can of tuna on the shelf available for use. During a concurrent observation and interview on 7/25/23 at 3:30 p.m., a review of AskUSDA (U.S. Department of Agriculture) indicated, .Discard deeply dented cans. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam. The information was discussed with DNS. DNS observed the surveyor place two fingers into the dented portion of the can demonstrating the can had a deep dent. DNS verified the can had a deep dent and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 14 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 should not be available for use for the residents. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 2011, the P&P indicated, .Dented or bulging cans should be placed on Damaged Goods Shelf and returned for credit . Residents Affected - Some 4. During a concurrent observation and interview on 7/25/23, at 10:25 a.m., with Director of Nutrition Services (DNS), in the dishmachine room in the main kitchen, an extensive amount of black colored substance was observed on the wall near the clean side of the high temperature dishmachine. DNS stated, he did not know if it was mold but verified the wall was not clean. DNS was able to easily rub off the black colored substance. During the same observation and interview, with DNS, in the dish machine room, DNS observed the covers over two light fixtures located on the wall were cracked and/or had missing pieces of cover, and black colored substances on the inside of the light fixture. DNS stated, he had not identified and reported the broken and dirty light fixtures for repair and/or replacement. DNS acknowledged the cracked fixtures had the potential to cause foreign object cross contamination to items located below and/or around the cracked covers. During a review of the facility's policy and procedure (P&P) titled, Walls and Ceilings, undated, the P&P indicated, Sanitation: .Walls and ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently as required .Lights should be covered and working . 5. During a concurrent observation and interview on 7/26/23, at 11:02 a.m., with Nutrition Services employee (NS) 3, in the main kitchen, NS 3 was observed wearing blue gloves and was next to a sink with running water where cantaloupe with intact rinds appeared wet, located on the counter top next to the sink. In the presence of the Director of Nutrition Services (DNS), NS 3 was asked how he washed the cantaloupe. NS 3 stated he washed them in the food preparation sink with water and used his gloved hand to run the water over the cantaloupe. NS 3 was asked if he used any foodservice utensil or if he solely used his hand to help run water over the cantaloupe, and NS 3 stated, just his hand. NS 3 was observed to proceed to use a knife to cut off the outside rinds of the cantaloupe. During an interview on 07/27/23, at 9:35 a.m., with DNS, DNS stated, he wanted to clarify the above observation to include that NS 3 also submerged the cantaloupe under water to soak in the food preparation sink. DNS was asked if NS 3 was trained to use a scrub brush on the outer rind of the cantaloupe prior to slicing, and DNS stated, no. During a review of the FDA Food Code Annex (Annex), dated 2022, the Annex, 3-302.15 titled Washing Fruits and Vegetables, the Annex indicated, All fresh produce, except commercially washed, pre-cut, and bagged produce, must be thoroughly washed under running, potable water or with chemicals as specified in Section 7-204.12, or both . Infiltration of microorganisms can occur through stem scars, cracks, cuts or bruises in certain fruits and vegetables during washing. Once internalized, bacterial pathogens cannot be removed by further washing or the use of sanitizing solutions. To reduce the likelihood of infiltration, wash water temperature should be maintained at 10°F warmer than the pulp temperature of any produce being washed. Because certain fruits and vegetables are susceptible to infiltration of microorganisms during soaking or submersion, it is recommended that soaking or submerging produce during cleaning be avoided . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 15 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm During a review of FDA Food Code Annex, 3-302.15 titled Washing Fruits and Vegetables, the Annex indicated, Scrubbing with a clean brush is only recommended for produce with a tough rind or peel, such as carrots, cucumbers or citrus fruits that will not be bruised easily or penetrated by brush bristles. Scrubbing firm produce with a clean produce brush and drying with a clean cloth towel or fresh disposable towel can further reduce bacteria that may be present. Residents Affected - Some During a review of Good Agricultural Practices for Melons (GAPM), supported by United States Department of Agriculture, the GAPM indicated, Pathogenic Behavior: Melons present one of the highest risks to consumers for microbial contamination. Melon rind is a particular challenge to food safety, as it is extremely susceptible to harboring bacteria. Harmful pathogens such as Salmonella and E.coli O157:H7 have been shown to stick to the exterior of melons, multiply, and travel though the porous rind to the interior of the fruit. (https://www.nifa.usda.gov/sites/default/files/resource/Melons%20Good%20Agricultural%20Practices508.pdf) During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 2011, the P&P indicated, Fresh Fruits .The outside surface of cantaloupe should be scrubbed with a clean brush and rinsed well. 6. During a concurrent observation, interview and record review on 07/26/23 at 9:40 a.m., with Licensed Nurse (LN) 2, a list titled Daily Check List For Rehab Break Room, posted to the outside of the refrigerator located in the rehabilitation (rehab) dining room was reviewed. The check list had items that included milk, juice, jello, thickened water, apple sauce, pudding, yogurt and ice-cream. LN 2 stated, the items were snacks/nourishments for residents. LN 2 opened the refrigerator that was observed to contain multiple items on the check list, and LN 2 stated, there was no internal or external thermometer for monitoring of the refrigertor temperature. LN 2 verified there was no posted temperature monitoring log for the refrigerator. During an interview on 07/26/23, at 09:42 a.m., with Registered Dietitian (RD), RD stated, it should be dietary department monitoring the temperature of the refrigerator located in the rehab dining room for food safety. During a concurrent observation and interview on 07/26/23, at 09:53 a.m., with Director of Nutrition Services (DNS), in the rehab dining room, DNS observed the inside of the refrigerator and freezer and verified there was no thermometer in the refrigerator or freezer compartment of the refrigerator. DNS stated, the check list of nourishments attached to the refrigerator is stocked by the dietary department. DNS was asked if the facility monitors temperature of the refrigerator, and DNS stated, the nurse's should be doing that, as the dietary department does not monitor temperature for that specific refrigerator. During a concurrent interview and record review on 07/26/23 at 11:24 a.m., with Director of Nursing (DON), DON stated, the night shift nursing staff should have been monitoring the temperature of the refrigerator in the rehab dining room used to store nourishments for residents. DON verified she was unable to locate a temperature monitoring log for the refrigerator. DON stated, the temperature monitoring log should have been taped on the refrigerator unit, and was not, and DON was unable to locate any previously completed temperature monitoring logs in a binder located in the DON's office. DON provided a document titled 11-7 Duties, that was a list of duties that nursing shift working from 11 p.m. to 7 a.m. should complete which included, Check all refrigerators for temps [temperature] - kitchen-refrigerator, freezer . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 16 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Record of Refrigeration Temperatures, dated 7/2014, the P&P indicated, Policy: A daily temperature record is to be kept of refrigerated items .The refrigerator must be clean and temperatures must be 41 degrees F [fahrenheit] or less ., Nursing unit refrigerators and freezers any any other refrigerators/freezers having resident food stored in it must .have temperatures recorded. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 17 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure its required QAA (Quality Assessment and Assurance) Committee (a committee organized by the facility which is responsible for developing and implementing corrective action plans for identified quality deficiencies) members included a credentialed Infection Preventionist [(IP - a staff trained to have oversight of the facility's infection prevention and control program (IPCP)]. Residents Affected - Few This failure had the potential to result in the facility's IPCP not getting implemented effectively which could lead to misinformation, inadequate surveillance and reporting, and spread of healthcare associated infections. Findings: During a review of the facility's policy and procedures (P&P) titled, QAPI (Quality Assurance Performance Improvement - an ongoing process that guides the facility's efforts in assuring care and services are maintained at acceptable level of performance), dated 11/6/17, the P&P failed to indicate the facility-designated IP as a member of the QAPI Committee. During an interview on 7/25/23, at 4:45 p.m., with the Director of Nursing (DON), DON verbalized overseeing the facility's IPCP together with another nurse. However, DON also verbalized not completing the required training to assume the IP role and stated, I have only completed 11 hours of the CDC (Centers for Disease Control) IP training and not certified. During a review of the CMS (Center for Medicare and Medicaid Services) Memorandum QSO-19-10-NH, dated 3/11/19, the memo indicated in part, . The CMS and CDC collaborated on the development of a free on-line training course in infection prevention and control for nursing home staff in the long-term care setting . Effective November 28, 2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's IPCP. The memo indicated further, . The course if approximately 19 hours long and is made up of 23 modules and submodules . In order to receive continuing education for the course and a certificate of completion, learners must complete all modules and pass a post-course exam During an interview on 7/28/23, at 11:03 a.m., with the Executive Director/Administrator ([NAME]), [NAME] verbalized the facility hasn't had a credentialed IP for approximately four years now due to a shortage in nurse staffing and the amount of time needed to complete the IP training. [NAME] also verbalized that currently, oversight of the facility's IPCP has been divided between the DON and Director of Staff Development (DSD) who were both registered nurses but have not completed the required IP training. [NAME] acknowledged that the facility should have a credentialed IP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 18 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed when: Residents Affected - Some 1. A Housekeeping Staff (HK 1) did not use gloves while sweeping and collecting trash inside a resident's room (room [ROOM NUMBER]), and did not perform hand hygiene after contact with potentially contaminated items. 2. A Licensed Nurse (LN 1) did not sanitize the handheld inhaler of one unsampled resident (Resident 34) before and after use and did not perform hand hygiene after contact with the resident. 3. LN 5 did not sanitize a glucometer test kit (a kit containing test strips and a device used to measure blood sugar) and perform hand hygiene after checking the blood sugar of one of 14 sampled residents (Resident 24). 4. Expired catheter stabilization device (a device, alternative to tape, used to secure catheters in place) and an opened, non-reusable wound care dressings were found in the treatment cart (storage for medical and treatment supplies). These failures had the potential to result in the spread of healthcare associated infections. Findings: 1. During an observation on [DATE], at 10:27 a.m., at the facility's north wing hallway, HK 1 and HK 2 were observed entering room [ROOM NUMBER] for routine housekeeping activities. room [ROOM NUMBER] was empty at this time. Upon further observation, HK 1 was collecting trash bags and sweeping the floor without gloves on. Without performing hand hygiene, HK 1 proceeded to replace the trash bags with clean ones. During an interview on [DATE], at 10:30 a.m., with HK 1 and HK 2, HK 1 verbalized being new to the job and with no housekeeping experience in a medical facility, which was confirmed by HK 2. HK 2 was training HK 1 as mentioned, but was not following a training plan. When asked if following standard precautions, such as wearing gloves to touch potentially contaminated items, was a requirement when performing their housekeeping duties, both verbalized yes. HK 1 was informed of not wearing gloves before collecting trash and sweeping the room, and not performing hand hygiene afterwards. Both acknowledged HK 1 should have worn gloves and performed hand hygiene. During a review of the facility's policy and procedures (P&P), titled, Infection Prevention and Control Program, dated [DATE], the P&P indicated in part, . 5) Written standards, policies, and procedures for the program which must include but are not limited to: .c) Standard and transmission-based precautions to prevent the spread of infections During a review of the facility's, P&P, titled, Terminal and Isolation Cleaning, dated 9/21, the P&P indicated in part, Policy: Staff should follow established terminal cleaning guidelines when performing housekeeping and/or laundry duties. The P&P also indicated, Procedures: 1) Wear appropriate personal protective equipment (PPE - equipment worn designed to protect the wearer's body from injury or infection) when entering room. Gown, gloves, mask . 6) Upon completion, remove PPE and thoroughly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 19 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 wash hands. Level of Harm - Minimal harm or potential for actual harm 2. During an observation on [DATE], at 7:50 a.m., a LN 1 was observed doing medication pass at the hallway just across the main dining room. LN 1 was preparing to administer an albuterol inhaler (inhaled medication to prevent and treat wheezing, difficulty breathing, and coughing) to Resident 34, who was sitting inside the dining room. Upon further observation, LN 1 failed to sanitize the inhaler and don gloves before administering the medication to Resident 34. LN 1 also failed to sanitze the inhaler before storing it back in the medication cart. Residents Affected - Some During a review of the facility's P&P titled, Infection Prevention and Control Program, dated [DATE], the P&P indicated in part, . Standard and transmission-based precautions to be followed to prevent spread of infections . f. The hand hygiene procedures to be followed by staff involved in direct resident care. During an interview on [DATE], at 4:45 p.m., with LN 3, LN 3 verbalized, the nurse administering the medication should sanitize hands first or don gloves before taking out the inhaler inside the medication cart. LN 3 further verbalized, the nurse would then sanitize the inhaler prior to giving it to the resident, inhaler would be sanitized again before storing it in the medication cart, and the nurse would perform hand hygiene. 3. During an observation on [DATE], at 7:58 a.m., LN 5 was observed performing a blood sugar check on Resident 24. After performing the procedure, LN 5 failed to sanitize the glucometer test kit before storing it back in the medication cart. LN 5 also failed to perform hand hygiene after removing the gloves used during the procedure. During an interview on [DATE], at 8:00 a.m., with LN 5, LN 5 was asked if the glucometer test kit was sanitized after using it on Resident 24. LN 5 stated, No, and acknowledged that the kit should have been sanitized. LN 5 also admitted not performing hand hygiene after removing the gloves worn during the procedure, and acknowledged it should have been done. During an observation, on [DATE], at 8:10 a.m., with LN 5, LN 5 demonstrated how the glucometer test kit should have been sanitized. LN 5 showed the disinfectant wipes the staff used to sanitize the glucometer test kit. The wipes came in individual pouches and contained 0.63% sodium hypochlorite solution (commonly known in dilute solution as bleach). LN 5 proceeded to sanitize the test kit as requested. During a review of glucometer test kit's, Manufacturer's Instructions for Use (MIU), the MIU indicated in part, . Use of (brand of wipes) Germicidal Wipes containing 0.55% sodium hypochlorite (bleach) and paper towels, cleaning carefully, keeping meter surfaces wet for 60 seconds, and drying with a paper towel. During a review of the facility's P&P titled, Blood Glucose Monitoring, dated [DATE], the P&P indicated in part, The licensed nurse shall perform the blood glucose testing as ordered utilizing the instructions from the testing device . The blood glucose meter shall be cleaned between residents. During a review of the facility's P&P titled, Glucometer Disinfection, dated 2017, the P&P indicated in part, The licensed nurse shall perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 20 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on [DATE], at 2:32 p.m., with the DON, DON verbalized, staff were expected to clean and sanitize shared equipment, like the glucometer, after each use. DON was informed that LN 5 was observed performing a blood sugar check to Resident 24 and failed to sanitize the glucometer test kit after using it, and LN 5 did not perform hand hygiene after removing the gloves worn during the procedure. DON acknowledged LN 5 should have sanitized the kit and performed hand hygiene afterwards. DON also verbalized, a staff in-service on glucometer disinfection was recently conducted and will remind all nursing staff about it. 4. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated [DATE], the P&P indicated in part, .promotion of a healthy and safe environment to reduce the risk of infections . During an observation on [DATE], at 2:15 p.m., at the facility's East Nurse Station, the contents of the main treatment cart was inspected. The cart contained an expired catheter stabilization device and an opened, non-reusable wound care dressing. During a concurrent observation and interview, on [DATE], at 2:30 p.m., with the Director of Nursing (DON), the DON visually verified the expired and opened, non-reusable items found in the treatment cart. The DON acknowledged the items found should have been discarded and not kept in the cart. During a review of the facility's, policy and procedures (P&P), titled, Storage of Medications, dated 9/18, the P&P indicated in part, . 14) Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 21 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atterdag Care Center 636 Atterdag Road Solvang, CA 93463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview, and record review, the facility failed to designate a credentialed Infection Preventionist [(IP - a staff trained to have oversight of the facility's infection prevention and control program (IPCP)]. Residents Affected - Few This failure had the potential for no coordination of infection control practices, increasing the risk of infections for residents, staff, visitors and others in the facility. Findings: During a review of the CMS (Center for Medicare and Medicaid Services) Memorandum QSO-19-10-NH, dated 3/11/19, the memo indicated in part, The CMS and CDC collaborated on the development of a free on-line training course in infection prevention and control for nursing home staff in the long-term care setting . Effective November 28, 2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's IPCP. The memo indicated further, . The course if approximately 19 hours long and is made up of 23 modules and submodules . In order to receive continuing education for the course and a certificate of completion, learners must complete all modules and pass a post-course exam During an interview on 7/26/23, at 9:30 a.m., with the Director of Nursing (DON), the DON verbalized that she performs the responsibility of the IP. DON further stated, I only have 11 hours of training and I am not certified. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention Plan, dated 2017, the P&P indicated in part, Division of Responsibilities for Infection Prevention Activities, IP or designee is ultimately responsible for the infection prevention program. The responsibility is delegated to the IP to carry out the daily functions of the IP program. The IP has knowledge of and interest in infection prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056353 If continuation sheet Page 22 of 22